Patient Authorization Form

PATIENT AUTHORIZATION FORM

Consent to Treatment: I voluntarily consent to receive such medical treatment that my provider considers necessary to me. I understand this care may include examinations, diagnostic tests and medical and/or surgical treatment. I acknowledge that no guarantee or assurance has been made as to the results of the examinations and treatments provided. (Patients who refuse to sign this Consent to Treatment may not be treated as a patient unless an emergency medical condition exists.)

Acknowledgement and Consent to Privacy Notice: I acknowledge that I have received the Notice of Privacy Practices of Kenneth J. Klak D.O., LLC. I understand that the Notice of Privacy Practices explains how Dr. Klak may use and disclose confidential health care information that identifies me. I consent to let Dr. Klak use and disclose health information about me as described in the Notice of Privacy Practices. In doing so I am consenting to the use and disclosure of health information about substance abuse, psychiatric care, or HIV, if applicable. (Patients who refuse to sign Dr. Klak’s Acknowledgement and Consent form may not be treated as a patient of Dr. Klak unless an emergency medical condition exists.)

Release of Information: I consent to the release of health care information about me to my insurer, other third party payers, Centers for Medicare and Medicaid Services and any agents or consultants that help me receive reimbursement of payment for Dr. Klak’s services. I can revoke my consent in writing at any time except to the extent that Dr. Klak has already relied on my consent.

Assignment of Benefits: In consideration of services received or to be received, I request payment for all authorized benefits be made directly to me. A photocopy or facsimile of this is considered as valid as the original. This assignment shall be irrevocable.

Advance Directives: You have the right to have Advance Directives (Living Will or Healthcare Power of Attorney). Please check if you have a:

____ Living Will ____ Health Care Power of Attorney

____ I do not have either document but would like more information. ______(Staff Initials)

____ Information offered to patient but was declined. ______(Staff Initials)

I authorize my health care provider to use my name in calling or e-mailing me with the date and time of my appointment as a reminder. I also authorize my healthcare provider to disclose to third parties who may answer my phone limited protection from health information regarding pending appointments, and to leave a reminder message on my voice mail or answering machine.

______

Patient Signature Date